South Africa small grant project, written by MJ Stowe, from South African Network of People Who Use Drugs (SANPUD).

Summary
Opioid-related drug overdoses occur when the amount of drug or combination of drugs consumed is toxic and negatively affects physiological functioning. Opioid overdoses are responsible for the majority of overdose deaths worldwide. More common than fatal overdoses are non-fatal overdoses (Degenhardt et al. 2019). Non-fatal opioid-related overdose is associated with significant morbidity (Glanz et al. 2019) and is the strongest predictor of experiencing a future overdose (Mathers et al. 2013). Naloxone is a safe, fast-acting opioid antagonist that can reverse an opioid overdose. Naloxone should be a critical component of community-based responses to opioid overdose. In South Africa, a prescription is required for naloxone for self-administration. To date, no community-based naloxone distribution programmes have taken place (Scheibe et al. 2020). As part of an activity as part of the African Small Grant, we provided naloxone trainings to street- based people in South Africa.

Introduction
Drug overdose is responsible for substantial mortality amongst people who use drugs, with an estimated 69 000 people dying from opioid-related overdose each year (WHO 2014).
Naloxone can reverse an opioid overdose. Naloxone is a semisynthetic competitive opioid antagonist with a high affinity for the μ opioid receptor. It rapidly displaces most other opioids from opioid receptors, and if given soon enough, will reverse all clinical signs of an opioid overdose (Kelty and Hulse 2017). Further, naloxone acts within seconds and has a short duration of effect and an elimination half-life of 60-90 minutes (Shaw et al. 2019). The World Health Organisation recommends naloxone distribution programmes as they reduce overdose rates and save costs (WHO, 2014). The administration of naloxone by non-medical bystanders (i.e. people who are more likely to be present at an overdose and could respond before medical professionals arrive) increases the chances of survival (Giglio and DiMaggio 2015).

South African context
There is very little data on the extent of opioid-related overdoses among people who use drugs in South Africa. Many of the country’s people who inject drugs live on the street and inject heroin, and it is likely that most fatal and non-fatal drug overdoses are occurring among this population. Currently, naloxone is registered and available as a hydrochloride solution in an ampule, typically 0.4mg per 1ml injection.

Training on Naloxone Administration
In South Africa, naloxone is only available as an intramuscular injection (Figure 2; 0.4mg per 1ml) and can only be obtained with a prescription.

Photograph of the intramuscular naloxone solution (0.4 mg/1 ml) available in South Africa.

Workshops were held in various contexts and participants included i) people who inject drugs; ii) friends and family of PWID; and iii) people who use drugs through other routes of administration. The aim of the workshops was to ensure that by the end of the session participants will be able to:

  1. be able to administer naloxone
  2. be informed and aware of naloxone’s various formulations
  3. demonstrate a clear understanding of evidence based overdose prevention and naloxone messages;
  4. identify observable signs and symptoms of a depressant overdose and advise on the appropriate response accordingly; and
  5. demonstrate the skills and knowledge to provide training and to supply take-home naloxone to people who use opiates.

Outcomes
This activity resulted in the following outcomes:

  1. The identification of champions in communities of people who use drugs, who can act as focal points and links between the community and relevant organisations.
  2. The training of more than 40 people in overdose prevention and responding to an overdose using naloxone.

Challenges

This activity encountered challenges, which include:

  1. The laws around naloxone. In South Africa, naloxone requires a prescription to obtain. For this activity, we had to recruit a healthcare professional to be present at the workshops and provide attendees with a prescription for naloxone.
  2. Challenging social dynamics. This resulted from the identification of champions who would be focal points for community engagements in the future. Sometimes, there wasn’t total agreement on the champion identified.
Overdose prevention and response training workshop in Durban, South Africa.

Conclusion
Through this YouthRISE grant, several trainings were held where participants were shown how to identify and respond to an opioid-related overdose by administering naloxone. Following the trainings, it is suggested that government enables civil society and academic institutions to establish opioid overdose prevention programmes, paired with appropriate administration training. Further, education around drug overdose in schooling systems is needed across South Africa.